Remedial Action Needed:Remedial Action Needed: Our failure to use formative research effectively

What works For Community-based Nutrition Programming?USAID’s IYCN Project Meeting 19 July 2011

Marcia GriffithsThe Manoff Group

USAID’s IYCN Project Meeting, 19 July, 2011

SUN principle:SUN principle:

“ Develop strong prioritized country Develop strong, prioritized country strategies”

• Epidemiological priorities following evidence-based pathways and recommended actionsbased pathways and recommended actions

• Behavioral priorities

Formative research best practicepSuccessful nutrition programs in the 1980’s

d t t d f d i idemonstrated power of designing a program using formative research, established a best practicebest practice

• Consumer/intended beneficiary • Qualitative ethno graphic style with• Qualitative, ethno-graphic style, with

quantitative aspects• Explain reasons behind the numbers the• Explain reasons behind the numbers—the

determinants of current behaviors• Determinants of new behaviors• Determinants of new behaviors

The challenge

The drift: research and program

Global templates reduce the use of research for program designof research for program design

Evidence of Formative ResearchEvidence of Formative Research

Local foods and terms are usedLocal foods and terms are usedLocal beliefs, seasonal differences and

cultural patterns are recognized andcultural patterns are recognized and addressed

Behavioral priorities among optimal p g ppractices are evident

Recommendations are specific and actionable

Motivations are caregiver-centered

Example—Behavioral PrioritiesG id li 9 11 th ldGuidelines: 9-11 month oldBreastfeed—8 times / day and nightFeed complementary food 3 x / day, plus

one snackOffer ½ cup – 2/3 cup of food at each mealOffer a variety of foods during the day:

i l f d it i A i h f danimal source foods, vitamin A-rich foods, a fat source

Off f d th t ft b t t li id fiOffer foods that a soft, but not liquid, finger foods

Rianne—9 months old

Katrina—10 months old

Robert—11 months old

Esmeralda—11 months old

Behavioral priorities varyBehavioral priorities varyIn common:--The need for increased diet diversity, but in

each case specific, local foods vary

Differences: Indo: +Density Kazak: + Increase BF/decrease tea; Feed meal in

afternoonafternoon Swaziland: + Sanitation and Density Bolivia: + Amount of food

Example—Within priorities, recommendations are eco e dat o s a e“actionable” & repeatableImproving dietary diversity (fromImproving dietary diversity (fromlocal foods) in Malawi and Rwanda:

1) feeding more food and 2) focusing on multiple additions:--greater variety of vegetables--fruit--animal source foods --a fat source

Improving Dietary Diversity: Overview

Generally every day one food was• Generally, every day one food was added/changed to improve diversity over the “customary” diet however not all changescustomary diet, however, not all changes were done every day (particularly in Malawi).

• Illness reduced dietary diversity drastically. Restoring diversity must be a focus of g yrecuperative feeding.

Insights: Overcoming key impediments of caregivers1) Amount Don’t want to waste food: Offered1) Amount--Don t want to waste food: Offered

more food per day as they improved diversity—amount was not specified

2) Reliance on porridge--What can be ) g“digested”: Reduced “thin” porridge-only meals and transitioned children older than 9 months to a more family oriented diet withmonths to a more family-oriented diet, with reassurance of easily digested foods

Insights: Overcoming key i di t f iimpediments of caregivers

3) Purchased snacks--Convenience/child wants: Substituted household foods such as a banana/fruit, piece of sweet potato, thick porridge with groundnut paste.

4) Sweet tea and sodas: Substituted breast )milk, lemon / orange juice and / or milk.

Insights reflected in program d tirecommendations

Need for specificity:p y1) By age:

6 - 8 months: special preparations9 11 months: add specific family foods9 - 11 months: add specific family foods

12 - 23 months: specific, special foods or substitutions

2) By day:Especially with animal-source foods caregiversEspecially with animal source foods, caregivers needed help to think about their alternatives each day. They could not offer an animal source food everyThey could not offer an animal source food every day, only 4 out of 7 days.

Insights reflected in program3) By food: --“Focus” foods:• Vegetables: not difficult family often had

g p g

• Vegetables: not difficult -- family often had green vegetables -- emphasize well cooked

• Animal source foods: dried fish (fish powder)• Animal source foods: dried fish (fish powder) and egg

• Source of fat: groundnut paste vegetableSource of fat: groundnut paste, vegetable cooked in oil or mashed fried food

4) By illness status

Insights reflected in program g p g

Motivations:While health is a motivator, caregivers spoke about child behavior:“child is more satisfied and less fussy”“child sleeps better”“child is happy and plays well”“child goes with others and leaves you to your work”

Tracking behavior changes f

MALAWI Visit 1 Visit 2

reflected in programMALAWI Visit 1 Visit 2

Mgaiwa porridge + other 30% 19%

Porridge + groundnuts 5% 8%Porridge groundnuts 5% 8%

Other CHO 8% 5%

Green vegetables 12% 15%Green vegetables 12% 15%

Beans and groundnuts 6% 10%

Fish, eggs & milk 7% 13%, gg

Fruit 5% 11%

Tea 5% 1%

Conclusion: Be a bridge builderDon’t let global templates limit caregiver insights (from research) for program design